Asperger Syndrome: A Developmental Perspective

1
Asperger Syndrome A Developmental Perspective

• Tina K. Veale, Ph.D.
• Eastern Illinois University
• Presented at the annual convention of the
  American Speech-Language-Hearing Association
• November 20, 2008
• Chicago, Illinois

2
Asperger Syndrome

• Autistic psychopathy
• (Asperger, 1991 1944)
• 4 boys, ages 6-11 yrs.
• Marked problems in social interaction despite
  appropriate language and cognitive skills
• Onset after 3 years of age, but earlier than
  schizophrenia
• Familial

3
Asperger Syndrome

• Asperger syndrome
• (Wing, 1981 1986 1989)
• First recognized as a diagnostic entity by the
  World Health Organization
• (ICD-10 1993)
• Soon after, recognized by the American
  Psychiatric Association
• (DSM-IV 1994)

4
Asperger Syndrome

• Asperger syndrome is a serious and chronic
  neurodevelopmental disorder which is presently
  defined by social deficits of the type seen in
  autism, restricted interests as in autism, but,
  in contrast to autism, relative preservation of
  language and cognitive abilities--at least early
  in life.
• Volkmar and Klin (2000)

5
Asperger Syndrome Language Impaired or Not?

• They all have one thing in common the language
  feels unnatural.
  (Asperger, 1944 1991, p. 69)
• If one listens carefully, one can invariably
  pick up these kinds of abnormalities in the
  language of autistic individuals, and their
  recognition is, therefore, of particular
  diagnostic importance.
  (Asperger, 1944 1991, p. 70)
• Unusual language profile
• Problems with conversation
• Unusual melody or flow of speech
• Atypical developmental history, including early
  or late language emergence
• Tendency to speak like an adult, with advanced
  vocabulary
• Use complex sentences

6
Criteria DSM-IV and ICD-10

• According to DSM-IV TR (APA, 2000) and ICD-10
  (WHO, 1993), individuals with Asperger syndrome
  present deficits in two areas
• Social interaction
• Eye to eye gaze, facial expression, body
  postures, gestures to regulate social interaction
• Immature peer relationships
• Lack of spontaneous seeking to share enjoyment,
  interests, or achievements with others
• Lack of social or emotional reciprocity
• Behavior
• Preoccupation with stereotyped, restricted
  interests
• Inflexible adherence to nonfunctional
  routines/rituals
• Repetitive motor mannerism stereotypies
• Preoccupation with objects or parts of objects

7
Criteria DSM-IV and ICD-10

• According to ICD-10 (WHO, 1989), individuals with
  Asperger syndrome may present deficits in
• Motor skills
• According to DSM-IV TR (APA, 2000) and ICD-10
  (WHO, 1989), individuals with Asperger syndrome
  present NO DEFICITS in
• Language
• Words by 2 yrs. communicative phrases by 3 yrs.
• No clinically significant general delay in
  language (APA, 2000, p. 84).
• Cognition
• Self-help skills
• Adaptive behavior (other than social interaction)
• Curiosity about their environment

8
Criteria Gillbergs

• According to Gillberg and Gillberg (1989),
  individuals with Asperger syndrome present
• Social deficits
• Extreme egocentricity
• Poor appreciation of social cues
• Inappropriate social and emotional responses
• Limited interests and preoccupation
• Repetitive involvement with objects of interest
• Some interests more rote than meaningful
• Repetitive routines or rituals
• Imposed on self and others
• Motor clumsiness
• Frequent, but not always noted

9
Criteria Gillbergs

• According to Gillberg and Gillberg (1989),
  individuals with Asperger syndrome present
• Speech and language peculiarities
• Delayed early development possible
• Superficially perfect expressive language
• Formal, pedantic language
• Odd prosody peculiar voice
• Impaired comprehension, especially with implied
  meanings tend to encode literal interpretation
• Nonverbal communication deficits
• Limited gestures
• Odd body language
• Inappropriate facial expressions
• Problems with proximity

10
Criteria Szatmari

• According to Szatmari and colleagues (1989),
  children with Asperger syndrome present at least
  two of the following
• Inflection abnormalities
• Talk too much
• Talk too little
• Lack of cohesive conversation
• Idiosyncratic use of words
• Repetitive speech

11
Language An Essential
Criterion

• Unusual language abilities are an essential
  characteristic of Aspergers syndrome and should
  be included in future revisions of the DSM
  criteria (Attwood, 2007, p. 203).
• Receptive language deficits, including problems
  with comprehension of sentences and following
  complex directions (Koning Magill-Evans, 2001
  Saalasti, et al., 2008)

12
Neurology of AS

• AS Right hemisphere disorder
• (Ellis, Ellis, Fraser, Deb, 1984 Ellis
  Gunter, 1999 McKelvey, Lambert, Mottron,
  Shevell, 1995 Voeller, 1986)
• Expresses as deficits with lateralized functions
  of
• Visuospatial organization
• Social-emotional processing
• Nonverbal communication
• Prosody
• Gestures
• Proximity
• Anatomical differences of right hemisphere found
  in SPECT imagining

13
Neurology of AS

• Differs from autism, a left hemisphere disorder
  (Escalante-Mead,
  Minshew, Sweeney, 2003 Fein, Humes, Kaplan,
  Lucci, Waterhouse, 1984)
• Expresses as deficits with lateralized functions
  of
• Language processing and production
• Beyond the cerebral cortex
• AS Subcortical disorder
• (Schultz, Romanski, Tsatsanis, 2000)
• Amygdala
• Thalamus--impaired cortical communication
• AS Cerebellar disorder
• (McKelvey, Lambert, Mottron, Shevell,
  1995)

14
Research Early Indicators
of Asperger Syndrome
15
Research Rationale

• AS is often diagnosed in late childhood or
  adolescence, whereas autism is now diagnosed much
  sooner (Eisenmajer, et al., 1996 Howlin
  Asgharian, 1999).
• Earlier detection leads to earlier intervention.
  
• Diagnosis is the first step in preventing
  potential behavioral and emotional issues common
  in AS (Attwood, 2007 Volkmar Klin, 2000).
• There remains controversy whether AS and autism
  are different disorders (Bishop, 2000 Schultz,
  Romanski, Tsatsanis, 2000 Volkmar Klin, 2000).
• While we know what the earliest symptoms of
  autism are, we do not know the earliest signs of
  AS.

16
Research Questions

• What are the earliest indicators of Asperger
  syndrome?
• What patterns of development are noted in the
  social-pragmatic, communication, and behavioral
  domains?

17
Research Design and Procedures

• Retrospective case study design
• Solicit, gather, and copy archival family video
  data
• Child with AS ages 0-5 years
• Gather case documents from families of
  individuals with AS
• Qualitative inquiry
• Identify and code behaviors through video editing
  and document review
• Triangulate findings
• Construct video records illustrating findings
• Describe findings from data record
• Quantitative inquiry
• Visual inspection of tabulated data
• Descriptive statistical analysis of data

18
Subject Selection

• 10 participants
• 7 complete video records (0-5 years of age)
• 3 incomplete video records (spanning at least 2
  years from 0-5 years of age)
• Complete medical and educational records
• 18 additional participants
• Complete medical and educational records
• No video
• Diagnosis of AS from at least two professionals
  with expertise in ASDs
• Normal hearing and visual acuity
• No concomitant medical issues affecting early
  development

19
Limitations of Video Analysis

• Limited data record
• Varying amounts of tape including subject
• Various amount of tape at each age interval
• No control over context
• Different social contexts different
  communicative opportunities
• Intimately personal at times
• Profanity nudity possible
• Quality of video varies
• Background noise
• Other people or their voices sometimes obscure
  subject
• Digital signal interference

20
Results Social-Pragmatics

• Social Engagement
• 100 (8/8) of infants demonstrated social
  engagement
• Gaze behavior social smile responsivity to
  people
• Ages 1-5 months

21
Results Social-Pragmatics

• Social Reciprocity
• 100 (8/8) of infants/toddlers showed turntaking
• Reciprocal play or vocalization
• Ages 5-18 months

22
Results Social-Pragmatics

• Joint Attention
• 100 (8/8) of subjects demonstrated coordinated
  joint attention
• Ages 7-12 months

23
Results Social-Pragmatics

• Initiation
• All infants/toddlers (8/8) started social
  interactions
• More prevalent in some than others
• Ages 6-18 months

24
Regression of Social-Pragmatic Skills

• TARYN
• 0-18 mos.-typical
• 19 mos.-repetitive play with kitchen toy
• 23 mos.-repetitive action in puddle
• 29 mos.-lack of JA with grandma at Christmas
• 36 mos.-lack of JA with peer in bathtub
• 49 mos.-lack of social engagement with baby
  sister
• 58 mos.-lack of interaction with sister in pool
• 60 mos.-beginning to demonstrate JA at 5th
  birthday

25
Regression of Social-Pragmatic Skills

• ADAM
• 3-7 mos.-Typical
• 20 mos.-No response to mother
• 24-36 mos.-Joint attention diminished
• 41 mos.-Plays apart from peers
• 48 mos.-Low social engagement with family/peers
• 50 mos.-Lack of interaction with baby brother
• 57-60 mos.--Joint attention and interaction begin
  to re-emerge

26
Social-Pragmatic Development Social Engagement,
Joint Attention, Reciprocity, Initiation
27
Social-Pragmatics Age 4-5 years

• Demonstrate a range of communicative functions
• Understanding needs of listener remains difficult
• Responding moves still not consistent
• Sharing enjoyment with others is not automatic
  requires direction
• Eye referencing is slow, awkward
• Joint attention is intermittent difficult to
  evaluate due to eye referencing differences
• Self-talk is still evident
• Theory of mind beginning to emerge, but an
  obvious challenge

28
Summary of FindingsSocial-Pragmatic Skills

• Emergence of foundational social-pragmatic skills
  of social engagement, joint attention,
  reciprocity, and initiation occurred for all
  subjects.
• For 7/8 (87), skills emerged in typical fashion.
• For 1/8 (13), skills were slightly delayed.
• All subjects experienced a loss of early
  social-pragmatic skills
• Characterized by slowing of eye referencing, loss
  of interest in social activities, loss of joint
  attention and initiation.
• One subject who experienced developmental delays
  had somewhat later regression of social-pragmatic
  skills.
• Skills gradually began to re-emerge.
• Significant deficits remained at age 4-5 years.

29
Results Expressive Communication

• ROSS
• 6-8 mos.-Babbling
• 18 mos.--Jargon
• 18 mos.--Spontaneous bye
• 24 mos.--Single words
• 30 mos.--Points/labels
• 32 mos.--Answers no
• 36-48 mos.--Multi-word prod.
• 52 mos.--Multi-turn exchange

30
Expressive Communication Development
31
Expressive Communication Development
32
Results Receptive Communication

• MATTHEW
• 5 mos.-Responds to name no
• 12 mos.-Follows simple direction
• 12 mos.-Answers questions
• 21 mos.-Answers variety of questions
• 36 mos.-Marked decline in language processing
  speed and accuracy
• 60 mos.-Fails to attend and respond to language

33
Receptive Communication Development
34
Receptive Communication Development
Of 28 subjects, only two parents described
regressive patterns. Others perceived
developmental delay in receptive communication,
most noting that their concerns began between 2-3
years of age when their child just seemed not to
be interested in or undestand language.
35
Results Unusual Communication Acts

• NATHAN ROSS
• Low regard for listeners
• Odd vocal quality
• Unusual prosody
• Repetitive language

36
Results Unusual Communication Acts

• ADAM MATTHEW
• Repetitive language Immediate echolalia
• Minimal
• Indicative of language processing difficulties
• Serves clear communicative purpose
• No evidence of delayed echolalia

37
Summary of Findings Communication

• Expressive communication emerges at expected ages
  or with slight delays.
• Video Analysis
• 8/10 (80) subjects--typical development
• 2/10 (20) subjects--mild to moderate delays
• Chart Review
• Mean age of attainment for all expressive
  milestones examined was in the average range.

38
Summary of FindingsCommunication

• Receptive communication emerges at expected ages,
  then slows or regresses.
• Video Analysis
• 9/10 subjects (90)--typical dev up to age 20-24
  mos.
• Language processing issues develop
• Parallels regression in social-pragmatic domain
• 1/10 subjects (10)--slow processing from early
  mos.
• Chart Review
• Mean age of early skills is in the average range.
• Mean age of following conversation is delayed.

39
Summary of Findings Communication

• Unusual communication acts
• Video analysis
• 10/10 subjects (100) showed odd vocal
  quality/prosody
• Some repetitive language was noted

40
Results Behavior

• Obsessive-Compulsive Tendencies
• 10/10 subjects (100) exhibited some OC
  tendency
• Obsessive use of objects, characters
• 4/10 (40) subjects demonstrated hyperlexia

41
Results Behavior

• Repetitive Behaviors
• Seen in 10/10 (100) of subjects
• Early indicators of need for order
• Precursor of cognitive inflexibility
• May involve purposeful or nonpurposeful play
• Occasional stereotypies (5/10 subjects 50)

42
Results Other Indicators

• Play Behavior
• 10/10 participants (100) showed early
  imaginative play by 4-5 years of age
• Play schema somewhat rigid underdeveloped
• Constructive play was not common due to fine
  motor deficits

43
Summary of Findings Behavior

• Obsessive-compulsive tendencies are pervasive in
  this population, and are evidenced early in
  development.
• 10/10 subjects (100)
• Repetitive behaviors are also common, and show up
  as one of the first indicators of the disorder.
• 10/10 subjects (100)
• Play must be scaffolded by adults
• May appear repetitive, or nonpurposeful
• Often needs help with construction toys
• Imagination begins to show by age 5
• 10/10 subjects (100)
• Cognitive inflexibility apparent in play schemas

44
Conclusions

• Social-pragmatic domain
• Typical from ages 0-18/30 months
• Social engagement
• Joint attention
• Reciprocity
• Initiation
• These early social skills diminish.
• Communication domain
• Expressive language emerges essentially on time
  for most children with AS.
• Occassionally, a child with AS presents mild
  delays.
• Receptive language emerges appropriately until
  18-30 months of age.
• Language processing speed and accuracy diminish
  at this time.

45
Conclusions

• Communication Domain
• Unusual communicative behaviors emerge
• Repetitive language immediate echolalia
• Odd vocal intonation/prosody
• Behavioral Domain
• Typical development until 18-30 months
• Repetitive behaviors emerge
• Possible stereotypies
• Increased noncompliance perhaps due to lack of
  processing

46
Conclusions

• Children with AS present typical development
  through the 0-18/24 month period.
• A developmental regression occurs between 18-30
  months of age.
• Regression is characterized by
• Loss of joint attention
• Interrupted eye referencing
• Language processing deficits
• Emergence of repetitive behaviors
• Unusual play behavior
• This regression is not frequently reported by
  parents.
• Many parents first become concerned between 2-3
  years of age, but do not describe a loss of
  skills.
• Loss of skills not as great as that of the
  autistic regression.

47
A Special Tribute

• To all of the families who gave of themselves to
  make this research possible
• Thank you for opening your lives to us so that we
  might grow in knowledge and understanding.
• Tina Veale, Ph.D., CCC-SLP

48
References

• American Psychiatric Association. (2000).
  Diagnostic and statistical manual of mental
  disorders (4th ed.-text revision). Washington,
  DC Author.
• American Psychiatric Association. (1994).
  Diagnostic and statistical manual of mental
  disorders (4th ed.). Washington, DC Author.
• Asperger, H. (1991)1944.Autistic psychopathy
  in childhood. In U. Frith (Ed.), Autism and
  Asperger syndrome. Cambridge Cambridge
  University Press.
• Asperger, H. (1944). Die Autistischen
  Psychopathen im Kindesalter. Archiv fur
  Psychiatrie und nervekrankheiten, 117, 76-136.
• Attwood, T. (2007). The complete guide to
  Aspergers syndrome. London Jessica Kingsley.
  
• Bishop, D. (2000). Whats so special about
  Asperger syndrome The need for further
  exploration of the borderlands of autism. In A.
  Klin, F. Volkmar, S. Sparrow (Eds.), Asperger
  syndrome (pp. 254-277). New York Guilford Press.
  
• Escalante-Mead, P., Minshew, N., Sweeney, J.
  (2003). Abnormal brain lateralization in
  high-functionsig autism. Journal of Autism and
  Develpmental Disorders, 33(5), 539-543.

49
References

• Ellis, H., Ellis, D., Fraser, W., Deb, S.
  (1994). A preliminary study of right hemisphere
  cognitive deficits and impaired social judgments
  among young people with Asperger syndrome.
  European Child and Adolescent Psychiatry, 3(4),
  255-266.
• Ellis, H. Gunter, H. (1999). Asperger
  syndrome A simple matter of white matter?
  Trends in Cognitive Sciences, 3(5), 192-200.
• Eisenmajer, R., Prior, M., Leekham, S., Wing, L.,
  Gould, J., Welham, H., Ong, B. (1996).
  Comparison of clinical symptoms in autism and
  Aspergers disorder. Journal of the American
  Academy of Child and Adolescent Psychiatry, 35,
  1523-1531.
• Fein, D., Humes, M., Kaplan, E., Lucci, D.,
  Waterhouse, L. (1984). The question of left
  hemisphere dysfunction in infantile autism.
  Psychological Bulletin, 95, 258-281.
• Gillberg, I., Gillberg, C. (1989). Asperger
  syndrome--Some epidemiological considerations A
  research note. Journal of the American Academy
  of Child and Adolescent Psychiatry, 30(4),
  631-638.
• Howlin, P., Asgharian, A. (1999). The
  diagnosis of autism and Asperger syndrome
  Findings from a survey of 770 families.
  Developmental Medicine and Child Neurology, 41,
  834-839.

50
References

• Koning, C., Magill-Evans, J. (2001). Social and
  language skills in adolescent boys with Asperger
  syndrome. Autism, 5, 23-36.
• McKelvey, J., Lambert, R., Mottrom, L.,
  Shevell, M. (1995). Right hemisphere dysfunction
  in Aspergers syndrome. Journal of Child
  Neurology, 10(4), 310-314.
• Saalasti, S., Lepisto, T., Toppila, E., Kujala,
  T., Laakso, M., Nieminen-von Wednt, T., von
  Wendt, L., Jansson-Verkaslo, E. (2008).
  Language abilities of children with Asperger
  syndrome. Journal of Autism and Developmental
  Disorders, 38, 1754-1580.
• Schultz, R., Romanski, L., Tsatsanis, K.
  (2000). Neurofunctional models of autistic
  disorder and Asperger syndrome Clues from
  neuroimaging. In A. Klin, F. Volkmar, S.
  Sparrow (Eds.), Asperger syndrome (pp. 172-209).
  New York Guilford Press.
• Szatmari, P., Bremner, R., Nagy, J. (1989).
  Aspergers syndrome A review of clinical
  features. Canadian Journal of Psychiatry, 34,
  554-560.

51
References

• Voeller, K. (1986). Right hemisphere syndrome in
  children. American Journal of Psychiatry, 143,
  1004-1009.
• Volkmar, F., Klin, A. (2000). Diagnostic
  issues in Asperger syndrome. In A. Klin, F.
  Volkmar, S. Sparrow (Eds.), Asperger syndrome
  (pp. 25-71). New York Guilford Press.
• Wing, L. (1981). Asperger syndrome A clinical
  account. Psychological Medicine, 11, 115-129.
• Wing, L. (1986). Clarification on Asperger
  syndrome (letter to editor). Journal of Autism
  and Developmental Disorders, 16(4), 513-515.
• Wing, L. (1998). The history of Asperger
  syndrome. In E. Schopler G. Mesibov (Eds.),
  Asperger syndrome or high functioning autism?
  (pp. 12-28). New York Plenum.
• World Health Organization. (1993). International
  Classification of Disease Tenth revision.
  Geneva Author.

52
Quick Reference Guide Characteristics of
Asperger Syndrome
53
AS Social Skills

• Modest to high social drive
• Over-initiation
• Command of reciprocity
• Intermittently emotionally present/connected
• Shows off
• Lack of sharing accomplishments/activities with
  others
• Few friends superficial relationships
• Deficient theory of mind
• Often perceived as abrupt or rude

54
AS Behavior Issues

• Cognitive inflexibility
• Ritualistic adheres to routines
• May demonstrate stereotypies
• Intense interest in one or more topics
• Obsessive-compulsive behavior patterns
• Policing behavior--makes sure others follow rules
  
• Fairness doctrine--demands that rules are applied
  equally to all

55
AS Communication Issues

• No clinically significant delay in language
  development
• Effortless verbal expression
• Receptive language may suffer
• May demonstrate pedantic speech
• Well developed expressive vocabulary
• Range of communicative functions
• Poor comprehension and use of nonverbal
  communication
• Facial expression, body language/gestures, vocal
  intonation proximity
• Difficulty with cognitive communication skills
• Verbal inferencing, problem solving,
  comprehension monitoring

56
AS Other Indicators

• No clinically significant delay in cognitive dev
• Attention deficit
• May have intense interest/focus on certain topics
• Play differences
• Little constructive play interactive play slow
  to emerge
• Most self help skills developed on time
• Dressing and toileting may be delayed
• Gross/fine motor deficits, including handwriting
• Curious about the environment
• Visual learner, but auditory skills may be strong
• Organizational difficulties
• Time/space estimation and management issues
• Sensory processing differences

57
Author Contact Information

• Tina K. Veale, Ph.D., CCC-SLP
• Eastern Illinois University
• 600 Lincoln Avenue
• 2207 Human Services Center
• Charleston, IL 61920
• [phone]
• tkveale_at_eiu.edu